By Janine L. Weisman/Rhode Island Health Fellowship
A man in his early 80s who came to see geriatrician Patrick Coll, M.D., complained of dizziness and hip pain that was bothersome but not severe. Over the previous 10 weeks, he had visited a specialist and had a battery of tests but still no clear diagnosis.
Coll listened to his patient and ordered a test for C-reactive protein — protein that increases in the blood in response to inflammation — and found the level was extremely high. Coll diagnosed him with polymyalgia rheumatica (PMR), an inflammatory disorder causing muscle pain and stiffness, and prescribed prednisone.
“The meds worked within hours,” said Coll, a professor and medical director for senior health at UConn Health and associate director for clinical geriatrics at UConn Center on Aging, during a panel on “Combatting diagnostic error in older adults” at Health Journalism 2024.
The panel outlined the challenges facing older patients and providers and pointed to promising efforts to improve the quality of care.
Arriving at a diagnosis is always challenging given there are over 10,000 diseases while symptoms number in the hundreds. Nearly 80% of diagnostic errors occur in the encounter between patient and provider during the information-gathering phase in a primary care setting, said panelist Allie Tran, Ph.D., a senior research scientist for the MedStar Institute for Quality and Safety in Washington, D.C., who started her career as a nurse.
Diagnosing older patients can be complicated by many factors, from complex medical histories, medications they are already taking and age-related cognitive impairments. And sometimes, the problem is a condition with vague symptoms like PMR, which Coll estimated he has encountered maybe 10 times in the past three decades.
But the low number of geriatricians like Coll is troubling.
In a country with 55.8 million people over age 65, there are only roughly 7,100 geriatricians with expertise in advanced illness care for older people, according to the American Geriatrics Society. There is a critical need to expand the geriatric provider workforce, yet the number of physicians matched to a fellowship for geriatric family and internal medicine was 174 last year, compared with nearly 1,200 who were matched for a fellowship in cardiovascular disease, according to data from the National Resident Matching Program.
When older patients end up in a noisy emergency department — perhaps transported by first responders, and without their glasses or hearing aid — they are especially vulnerable, said speaker Gallane Abraham, M.D., associate director of geriatric emergency medicine for Mount Sinai Health System in New York.
“The emergency department setting is a very high risk encounter for the older adult,” Abraham said.
That has led over 500 hospitals to seek Geriatric Emergency Department Accreditation (GEDA). These departments seek to improve the quality of care for older patients. They enhance their spaces and equipment with non-glare floors, lighting changes (eg, prioritizing soft and natural lighting), large signage and sturdy high back chairs to offer a more comfortable environment and reduce the risk of cognitive and communication challenges, Abraham said. Specialized care teams offer screening for delirium, dementia and fall risk.
Another promising trend: More momentum to build research about high-risk populations and developing potential interventions. Tran said she is seeing more calls for funding and more opportunities focusing on reducing diagnostic errors.
“Stay tuned,” Tran said. “There’s a lot more coming out.”
Janine L. Weisman is editor-in-chief of the Rhode Island Current, part of the States Newsroom network. She was a 2024 AHCJ-Rhode Island Journalism Fellow.
